Workers' Comp Insurance Claims: Complaints, Denials, and Appeals



The Five Most Common Complaints about the Workers' Compensation Process are:

1. "My Claim Was Denied."

The initial denial of a claim is a major issue in workers' comp cases. Insurance companies are under pressure from their clients (employers) to keep premium costs as low as possible. They carefully scrutinize claims for opportunities to deny or reduce benefits. The more claims they pay, the higher the premiums they must charge their clients.

2. "It's Taking Too Long to Process My Claim."

A contested workers' comp claim may take up to two years to finalize. A claim can stall out for several reasons. Pre-hearing discovery and depositions can be lengthy and time consuming. Having to seek additional opinions to establish maximum medical improvement (MMI) can also prolong your claim.

3. "The Settlement Amount Isn't Fair."

This is a frequent complaint. Workers' compensation laws don't normally allow compensation for pain and suffering. Settlement offers and administrative judge's awards are limited to partial wage reimbursement, medical bills, and in some cases, set amounts for loss of limbs, permanent debilitation, and other cases of severe loss.

4. "My Employer Fired Me Because I Can't Return To Work."

An employer cannot legally terminate a worker because he files a workers' compensation insurance claim. The situation becomes difficult when a doctor certifies a worker as able to return to work and the worker disagrees with the doctor's opinion. Once an injured worker is medically cleared to return to work and he refuses to do so, an employer has the right to terminate him (barring termination due to race, color, creed, gender or sexual preference).

5. "I'm Still Suffering from Pain and Discomfort."

Pain is subjective and impossible to accurately measure. While a doctor may diagnose an injured worker as reaching maximum medical improvement, the worker may disagree. If the MMI diagnosis or allowed recovery time are not acceptable, the best thing to do is seek another medical opinion.

Filing a Complaint

If you have credible evidence that your claim was denied as a result of fraud, administrative error, or other irregularity, you can contact your workers' comp administrative office and request a complaint form. (Each state has a unique version of the form.) When you file a complaint, it goes through a review process. If your complaint has legal merit, it may support your case and influence the amount of your settlement.

Common Reasons for Claim Denials

There are a number of reasons your claim may be denied. Among the most common are:

1. Failure to Promptly Notify Your Employer of Your Injury

You must immediately (or as soon as reasonably possible) notify your employer of your injury. Under your workers' comp insurance coverage, your claim doesn't begin until you report your injury to your employer. While each state has its own time limitations, it's usually about 30 days.

2. Failure to File Your Claim within the Statutory Time Period

Reporting your injury and filing your claim are two different processes. There is a statutory time period in which you must formally file your workers' comp claim, referred to as the Statute of Limitations period. Missing that filing period is grounds for denying your claim.

Each state has its own filing period. For example, in the State of California, you must file your workers' comp claim within one year of the discovery of your injury. The State of Florida's filing period is within two years of the employee's injury, or the date by which the employee should have discovered the injury.

3. Your Injury Occurs Outside of Employment

Your injury must occur while performing your work duties on your employer's premises, or off-site while pursuing the duties assigned to you by your employer or supervisor. If your injury occurs before or after normal work hours, even if you are volunteering your services to complete a work task, your injury may not be covered.

For example, if you sprain your ankle while walking to a deli to pick up lunch for yourself or your coworkers, your claim will probably be denied. However, if you are also picking up lunch for your boss, there's a chance (but no guarantee) your injury may be covered.

4. Your Injury Occurs While You Are Under the Influence

Regardless of how hard you work, how long you've been employed, or what type of work you're doing, if you are under the influence of illegal narcotics or alcohol when you're injured, expect your claim to be denied.

Technically, you don't have to be fall-down drunk. If proof exists that self-ingested illegal narcotics or alcohol are even a small factor in your injury, your claim will probably be denied. Even if you are under the influence of prescribed medications at the time of your injury, your clam may be denied.

5. Your Employer Disputes Your Injury Claim

An employer may dispute your claim by stating that your injury is pre-existing, it occurred outside of the scope of your employment, or that your injury is faked. As an employee, you are responsible for proving the legitimacy of your injury.

6. Your Medical Condition Isn't Covered

Most workers' comp insurance claims based on a mental health issue are initially denied. To be covered, you must be able to link your mental issues to a specific event, such as a trauma you experienced while working. Most states cover psychiatric injuries from specific events, such as post-traumatic stress disorder (PTSD). Even conditions arising over time, such as depression and severe anxiety, may be covered.

The difficulty is convincing the insurance company your mental health issues are directly linked to your job duties. This requires clear and convincing medical evidence, such as a descriptive diagnosis and prognosis of your condition from a licensed psychiatrist.

7. Your Injuries Aren't Serious Enough To Be Covered

What you think is a debilitating injury may not be considered as serious by your employer or the insurance company. Your injury must limit or fully prohibit you from completing your job duties. You may injure your back while loading boxes, but if the pain is only temporary your claim will likely be denied. Even if you believe your injury is debilitating, you won't convince the insurance company unless you have a doctor's opinion to back you up.

Appealing a Denied Claim

Having your claim denied can be frustrating, but it doesn't have to end there. You have a right to dispute its denial. The denial letter you receive should include an explanation of your workers' comp insurance coverage, your appellate rights, and notify you of the deadline for filing your appeal. State deadlines vary, but are usually between 30 to 90 days.

Missing the filing deadline for your appeal can end any possibility of getting compensation. Be sure to review the workers' comp regulations and appellate deadlines in your state.

Reopening a Workers' Comp Claim

Reopening a workers' comp claim is altogether different than appealing one. Reopening a previously closed claim is possible under some conditions. The most common are:

  • Your injury has recurred, worsened or become aggravated.
  • The lighter alternate job duties or job no longer exist.
  • New evidence proving your injury claim is found.
  • New evidence shows the compensation award was inadequate or unjust.
  • A legal or administrative error caused an unfair result.
  • Fraud is discovered.

Time limitations for filing a request to reopen your claim are set by each state. They can range from three to seven years from the date your original claim was denied - not the date of your original injury. Some cases are considered closed when a full and final payment is issued and a release is signed. In these cases, neither you nor your insurance company can reopen the claim.

The process of reopening a denied claim varies from state to state. It usually requires filing an application with the Workers' Compensation Commission in your area. (Your state may have a different name for the Commission.)

Contact them and request the appropriate form required to reopen your claim. Be sure to follow the rules set out in the form. You must state the reason for your request and provide supporting documentation. You may need to include a copy of your denial letter. For example, if your injury has worsened since you filed your original claim, send in a new medical evaluation diagnosing your condition and linking it to the work event which was the basis of your original claim.

Reopening Your Claim after the Statute of Limitations Period Has Expired

Most state laws allow workers' compensation appellate judges great discretion in setting the statute of limitations period. Generally, judges define the statutory periods in favor of the claimant, especially when it has technically expired. The nature of many injuries makes determining the onset of an aggravation or worsening of a previous injury tough to establish.

Although legally possible, reopening a previously closed workers' comp claim is extremely difficult. Most workers' compensation commissions are already overloaded with claims and will look for any reason to refuse your request. Insurance companies always oppose reopening old claims, especially when there's a chance they will have to pay not only the claim, but also compensate you retroactively.

Because of the challenges against reopening a claim, it's a good idea to consult with a workers' comp attorney. In some cases, retaining an attorney for the original claim could ensure a better outcome. Perhaps it won't even be necessary to go through the appellate process.

The Role of Attorneys

The initial filing of most workers' comp claims can be handled without an attorney. When you believe your claim is being unnecessarily delayed or has been unfairly denied, you may need legal assistance. Most workers' comp attorneys will not charge for an initial office consultation. You have nothing to lose and everything to gain by visiting with one or more.

Case Studies:

Insurance Carrier Denied Payment
In this case, the plaintiff (the Special Disability Fund), is refusing payment to a workers' comp insurance carrier due to a late filing of a request-for-payment form.

Insurance Company Denying Benefits
If you are employed in one state and injured in another, will you be covered? In this claim, the insurance carrier is denying an employee's benefits because he was injured in another state.

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